A nurse is taking care of an 85-year-old woman in a hospital-based skilled nursing facility. In the report, the nurse is told the patient has not been breathing well for the past 2 days. She has been lethargic, her skin is warm and dry, and she has a decreased urine output. The following laboratory findings were returned from the laboratory immediately after the morning report:

Blood Chemistries

Na: 147
Cl: 110
K: 4.0
Arterial Blood Gases

pH: 7.33
PCO2: 48
HCO3: 27
PO2: 96
Urinalysis

Urine Specific Gravity: 1.040
Address the following:

Identify each of the abnormal laboratory findings in the above results. Specify how they differ from a normal range and identify what condition each abnormality indicates.
What specific electrolyte disturbance does the patient have?
What clinical manifestations would the nurse expect to see with this electrolyte abnormality presented above?
If the patient had an increase in her potassium level, for what clinical manifestations would the nurse monitor?
What blood gas abnormality is seen in this patient? Discuss the rationale for your answer.
What are the three major mechanisms of pH regulation?
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Solution

Laboratory Findings

The blood chemistries show elevated sodium and chloride levels with normal potassium levels. A high sodium level above 143mEq/l is hypernatremia. Causes of hypernatremia are severe dehydration from acute volume loss or diarrhea. The chloride levels for this patient are 110, which is slightly higher than the normal value of 106. This is a sign of hyperchloremia. Causes of hyperchloremia are metabolic acidosis, dehydration, excessive salt intake, and electrolyte imbalance. The potassium level is within the normal value.

Arterial blood gases show slightly low PH levels, higher bio-carbonate, elevated partial pressure of carbon dioxide, and normal oxygen saturation. PH of 3.3 is a sign of metabolic acidosis. Slightly elevated bio-carbonate and partial pressure of carbon dioxide level is a result of electrolyte imbalance or dehydration. Changes in arterial blood gases indicate electrolyte imbalance (Pin-On, et al, 2018). The urine-specific gravity elevated. It is an indication of mild dehydration.

Patient Electrolyte Imbalance

The patient suffers from hypernatremia and hyperchloremia due to the elevated sodium and chloride, increased partial pressure of carbon dioxide, decreased PH, and elevated bio-carbonate.

Clinical Manifestation Of The Electrolyte Imbalance

Electrolyte imbalance in elevated sodium and chloride levels presents with lethargy, confusion, seizure, numbness of extremities, tingling sensation, sweating, tachycardia, tachypnea, oliguria, dry oral mucosa, dry axillae, abnormal skin turgor, abnormal speech, irritability, weight loss, and generalized weakness.

High Potassium Levels

Hyperkalemia is elevated potassium levels greater than 5.5mEq/l. Causes of hyperkalemia are destruction of red blood cells, excessive potassium supplement use, severe dehydration, and adrenal deficiency (Hunter, et al, 2019). Clinical presentation includes muscle paralysis, dyspnea, palpitations, chest pain, paresthesia, nausea, and vomiting. The nurse should monitor the heart rate to check for bradycardia due to the heart block. They should also monitor the respiratory rate. The patient has tachypnea due to respiratory muscle weakness.

Blood Gas Abnormality

The blood gas abnormality in this patient is metabolic acidosis due to low PH, slightly elevated bio-carbonate, and partial pressure of carbon dioxide level. Acidosis is the build-up of acid levels in the blood due to severe dehydration. The cause of metabolic acidosis in this patient is hyperchloremia and hypernatremia. Hyperchloremia causes the loss of sodium bicarbonate due to severe dehydration.

Three mechanisms of PH regulation

Mechanisms of PH regulation are chemical buffer, respiratory system, and urinary system. Chemical buffer regulates the PH levels by increasing the concentration of hydrogen in elevated acid levels. The H+ ion binds to the hydrogen reducing the carbon dioxide levels. The respiratory system helps in acid-base balance by regulating the carbon dioxide is in the blood (Venn, et al, 2019). During respiration, there is rapid hyperventilation that decreases the carbon dioxide in the blood thus reducing the bicarbonate in the blood. The renal system helps in regulating the PH by absorbing more acids and producing bicarbonate when needed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Hunter, R. W., & Bailey, M. A. (2019). Hyperkalemia: pathophysiology, risk factors and consequences. Nephrology Dialysis Transplantation, 34(Supplement_3), iii2-iii11.

Pin-On, P., Saringkarinkul, A., Punjasawadwong, Y., Kacha, S., & Wilairat, D. (2018). Serum electrolyte imbalance and prognostic factors of postoperative death in adult traumatic brain injury patients: A prospective cohort study. Medicine, 97(45).

Venn, A. A., Tambutté, E., Caminiti-Segonds, N., Techer, N., Allemand, D., & Tambutté, S. (2019). Effects of light and darkness on pH regulation in three coral species exposed to seawater acidification. Scientific reports, 9(1), 1-12.